Technical Surgical Failures: Presentation, Etiology, and Evaluation Carrie A

8 Technical Surgical Failures: Presentation, Etiology, and Evaluation Carrie A. Sims and David W. Rattner Approximately 48,000 patients undergo anti- surgery, many perceive that residual symptoms reflux procedures each year in the United States. represent an indication of fundoplication Although surgery is the most effective treatment failure.It is well known,however,that symptoms for gastroesophageal reflux disease (GERD),anti- correlate poorly with the presence of acid reflux reflux operations have reported failure rates after fundoplication. Soper and Dunnegan1 between 3–30%.This wide variability reflects dif- found that 26% of those undergoing laparo- ferences in operative technique,differences in the scopic anti-reflux surgery reported postopera- length of reported follow-up, and differences in tive foregut symptoms. After an extensive the definitions used to describe failure. For the evaluation, 35% had no demonstrable abnor- purposes of this chapter, failure is defined as the mality and their symptoms resolved without development of recurrent or new symptoms after intervention.1 Galvani et al.2 studied 124 anti-reflux surgery combined with documented patients with persistent or recurrent foregut pathologic gastroesophageal reflux or anatomic symptoms after laparoscopic fundoplication. failure. Failures occurring within the first 3 Only 39% were found to have acid reflux by 24- months of surgery are termed early failures and hour pH monitoring. Viewed another way, two- are generally caused by technical errors.Diaphrag- thirds of the patients who were taking matic stressors such as coughing,straining,vom- acid-reducing medications postoperatively were iting,retching,and weight lifting increase the risk found to have normal 24-hour pH probes of recurrence, especially in the early postopera- studies (the studies were performed off med- tive period. When failures occur after 3 months, ication).2 Almost every patient experiences they are termed late failures and a combination some degree of dysphagia in the early postop- of factors may be responsible. The size of the erative period. In a review by Perdikis et al.,3 original hiatal hernia, increased intraabdominal dysphagia occurred in 20% of the 2453 patients pressure,the presence of Barrett’s esophagus,and analyzed. Initial dysphagia may be secondary to the use of steroids predispose to late failures.This distal esophageal edema or transient esophageal chapter will discuss the evaluation and man- dysmotility and most patients can be treated agement of failed fundoplications. expectantly. Given the disparity between symptoms and demonstrable anatomic or physio- Presenting Symptoms of logic abnormalities, documenting functional status with appropriate testing must be per- Failed Anti-Reflux Operations formed before ascribing symptoms after fundoplication to a failed operation. Patients with GERD often have associated Patients with failed anti-reflux surgery typi- gastrointestinal motility disorders. Because cally complain of dysphagia, heartburn, vomit- patients have high expectations of anti-reflux ing, or a combination of these symptoms.4 The 91 92 MANAGING FAILED ANTI-REFLUX THERAPY Figure 8.1. Upright abdominal radiograph demonstrating a dilated gas-filled stomach consistent with the gas bloat syndrome. majority of symptomatic recurrences occur Patients with an improperly constructed fundo- within 2 years.5 Patients whose dysphagia per- plication may not be able to easily belch and sists for more than 3 months postoperatively painful abdominal bloating may arise when should be suspected of having an anatomic swallowed air is “trapped.” This is readily diag- problem. In the early postoperative period, sub- nosed with a plain film of the abdomen showing sternal chest pain or discomfort is another a distended gas-filled stomach (Figure 8.1) or in common symptom.Although the etiology is not the absence of an X-ray, prompt relief of pain by well understood, the pain may be secondary passage of a nasogastric tube. The “gas bloat to esophageal spasm, irritation from the syndrome” should be differentiated from the esophageal dissection and mobilization, or more common complaint of generalized referred pain from the crural repair. The pain abdominal bloating and increased flatulence as may be described as a dull ache although some the latter tends to resolve on its own over time. patients describe it as heartburn. Usually this, too, can be managed conservatively.Vomiting in the postoperative setting is very abnormal and Methods of Evaluation often signifies disruption of the fundoplication. More ominously, it may be the presenting sign Given the poor correlation between symptoms of an incarcerated iatrogenic paraesophageal and anatomic failure, a careful and thorough hernia.If a patient experiences severe chest pain evaluation is warranted. A complete history and in the setting of retching or straining, the diag- physical should be performed with particular nosis of a transhiatal herniation of the wrap attention to the patient’s current symptoms.Are should be considered. This is a surgical emer- the symptoms similar to those experienced gency and a water-soluble contrast study should before the original surgery? Do symptoms of be done immediately to confirm the diagnosis. reflux or dysphagia predominate? Was there a If herniation is present, the patient should be precipitating event? Do antacid medications returned expeditiously to the operating room ameliorate the symptoms? The patient’s original for a laparoscopic or open reduction of the operative report should be obtained to clarify herniated stomach. the type of fundoplication and extent of dissec- Whereas dysphagia and heartburn are the tion. Any prior preoperative radiographs and most common symptoms after fundoplication, physiologic test results should also be obtained rarely, patients may complain of “gas bloat” and reviewed. If the patient’s symptoms are characterized by the onset of severe epigastric identical to their prior symptoms of reflux, a 2- pain approximately 30 minutes after eating. week trial of omeprazole at 40mg/d should be 93 TECHNICAL SURGICAL FAILURES: PRESENTATION, ETIOLOGY,AND EVALUATION initiated. Symptoms that completely resolve on these changes may impact the decision to reop- this regimen should raise suspicion for recur- erate or treat medically. rent reflux. The patient can be offered a contin- Esophageal manometry should be routinely ued course of medical therapy as a reasonable performed before considering reoperation. option. Many patients feel so well after success- Manometry provides an objective means of ful anti-reflux surgery, however, that they prefer assessing the location and resting pressure of another operation to a lifetime of medical the lower esophageal sphincter. It can also therapy. If the patient does not respond to provide an assessment of the functional status omeprazole or has symptoms of dysphagia, the of esophageal peristalsis and sphincter relax- work-up should proceed with more invasive ation. Manometric studies are critical when monitoring and diagnostic studies in an attempt to elucidate the etiology of their symptoms. A barium swallow should be the initial diagnostic study in the work-up of any symptomatic patient. This relatively noninvasive, inexpensive study will define the patient’s anatomy and help clarify the relationship of the gastroesophageal junction to the hiatus. This study may also demonstrate gastroesophageal reflux and can detect evidence of delayed esophageal empty- ing. A barium swallow is particularly helpful when the patient presents with symptoms of dysphagia or pain and can help delineate a gross anatomic defect that might explain the patient’s symptoms (Figure 8.2). However, the failure to visualize reflux on a barium study does not exclude the possibility that the patient is expe- riencing pathologic reflux. Because patients may have symptoms consistent with reflux without evidence of gastroesophageal reflux, a 24-hour pH study is important in patients whose anatomy seems to be intact. This functional study confirms the presence of pathologic gastroesophageal reflux. By maintaining a 24- hour diary, the patient’s subjective assessment of reflux can be correlated with monitored episodes of reflux. Patients who have “reflux” symptoms, but a normal 24-hour pH study, are likely to have another cause for their symptoms and will not benefit from refundoplication. Upper gastrointestinal endoscopy should be routinely performed in evaluating patients who are symptomatic after a fundoplication. Endoscopy and barium swallows provide complementary information. In up to 10% of patients, an endoscopy will reveal an anatomic problem not appreciated by a barium swallow.6 In particular, endoscopic evaluation may reveal a “spiraling” or “twisting” of the wrap that may be missed by standard barium studies (Figure 8.3). Endoscopy also helps assess complications of gastroesophageal reflux such as esophagitis Figure 8.2. A barium swallow demonstrating a slipped Nissen and Barrett’s mucosal changes. The degree of fundoplication. 94 MANAGING FAILED ANTI-REFLUX THERAPY Failure can occur at the esophageal, wrap, or crural level, although there may be overlapping or concurrent issues. Before the wide adoption of laparoscopic techniques,wrap disruption was the most common mode of failure. In the laparoscopic era, the most common cause of failure is herniation of the wrap through the diaphragmatic hiatus. The construction of a fundoplication (particularly a 360° fundoplication) may unmask pre-

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